PN Adult Medical Surgical Practice Exam

What intervention should be part of the care plan for a client at risk for increased intracranial pressure (ICP)?

1. Measure rectal temperature every 4 hr.

2. Remind the client to cough as needed.

3. Use a turn sheet to reposition the client.

4. Apply wrist restraints.

The correct answer is: Use a turn sheet to reposition the client.

In managing a client at risk for increased intracranial pressure (ICP), using a turn sheet to reposition the client is a critical intervention. This method allows for smooth and gentle movements, minimizing the risk of increasing ICP during repositioning. Maintaining proper alignment and head elevation can prevent further complications associated with elevated ICP. Minimizing stress and exertion on the brain is vital; therefore, careful handling during movement ensures that the client's condition remains stable. Repositioning is important but should be done thoughtfully to avoid any sudden changes in pressure or increased intracranial tensions that could arise from abrupt movements or straining. In contrast, measuring rectal temperature may not directly address ICP management and could be uncomfortable for the patient. Encouraging coughing can lead to increased pressure in the cranial cavity, which should be avoided. Applying wrist restraints is not typically a standard intervention for managing ICP unless the client is at risk of harming themselves due to agitation or confusion, which does not directly mitigate the risks associated with ICP.